Hearts Youth Summer Camp

HOF YOUTH SUMMER CAMP REGISTRATION

Chesnut Bay Resort
Student Information

Please fill out one form per student.
Students Name

First Name Last Name
Birth Date

Month Day Year
Grade
Gender

Male Female
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/Guardian Information
Name

First Name Last Name
Home Number
Cell Number
E-mail
example@example.com
Emergency Information
Emergency Contact's Name

First Name Last Name
Relationship
Phone Number
Alt. Phone Number
Does the student have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is the student prescribed any medications that we need to know of? If yes, please explain any instructions.
Students Insurance Card

please scan and upload a copy below of the students insurance card.
Insurance Card information

Cancel of
Informed Consent and Acknowledgement I hereby give my approval for my child’s participation in any and all activities prepared by {Hearts on Fire Youth} during the selected camp. In exchange for the acceptance of said child’s candidacy by {Hearts on Fire Youth} ., I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless {Hearts on Fire Youth} . and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions. In case of injury to said child, I hereby waive all claims against {Hearts on Fire Youth} . including all Volunteers and Pastors, and all participants, used to conduct the event.
LETTER of AUTHORIZATION for TRAVEL and PARTICIPATION

I the Parent agree to authorize my child to travel to Chesnut Bay Resort, In Leesburg, Alabama on Sunday the 24th–Wednesday 27th
Medical Release and Authorization As Parent and/or Guardian of the named athlete, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed. Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me. Permission is also granted to the {Hearts on Fire Youth} . and its affiliates including Pastors and Volunteers on the trip to provide the needed emergency treatment prior to the child’s admission to the medical facility. Release authorized on the dates and/or duration of the registered season. This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
Camp Rules

when submitting you agree to read these over with your student.
- You will be assigned a buddy and must know where your buddy is at all times.
- Respect other people’s property. If it’s not yours, don’t touch it.Keep track of your own property, and know where it is at all times.
- You may not go into a house other than your own without counselor permission.
- Girls cannot visit boy’s houses or rooms, and boys cannot visit girl houses or rooms unless we are all meeting there for breakfast lunch or dinner. They must stay in the same meeting place and not visit any other rooms in the home.
- Clothing – NO bare midriffs, spaghetti straps, bikinis (one piece swimsuits must be worn); short shorts (shorter than arm’s length) or Shirts with offensive language or pictures are allowed.
- You have broken the rules if you are involved in fighting, pretend fighting, teasing, put downs, gossip or hurting another person, even if you didn’t start it.
- Show respect to nature and camp by not littering and respecting the resort and the rules of the resort.
- Stay within boundaries discussed on first day. Do not wander off!
- Cellphones are allowed but we will ask them to be mostly put away only there to contact parents if needed.
- NO matches, lighters, fire starters, pocket knives or weapons of any kind.
- NO cigarettes, vapes,drugs,alcohol,,marijuana or other illicit/illegal substances.
- Respect each other and all camp volunteers and staff.
Please Download or print the PDF below with instructions, rules about camp and what to bring.
Summer Camp Registration Costs please choose one. *
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Deposit
$ 100.00

Remainder after deposit paid
$ 125.00

Full Amount
$ 225.00

Pay in Person
Free

Total

$ 0.00
Hearts on fire is using paypal for the payment method. You do not need a paypal account to submit payment. PLease choose (USE DEBIT OR CREDIT) if you do not have an account. When entering in your card information choose checkout as guest.
Confirmation BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
I agree to all the above.

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HOF YOUTH SUMMER CAMP REGISTRATION

Students Insurance Card

Camp Rules